Is compensation "bad for health"? A systematic meta-review

[Frequency of Chronic Pain after Work-Related Trauma: A Preliminary Status Survey during Workers' Compensation Rehabilitation in a Tertiary Clinic]

BACKGROUND

Chronic pain after trauma and surgery is a long-term complication. Its relevance for patients within the workers' compensation rehabilitation process has not been adequately investigated.

OBJECTIVES

Initial evaluation of frequency of chronic pain after occupational accidents.

METHODS

In 2017, surgical inpatients (18-65 y) treated in a tertiary hospital were asked about chronic pain arising from an occupational trauma recognized by statutory occupation insurance (interval 2.8±6.9 years), regardless of care received, first at the time of hospitalization and then by telephone interview 6 months later. The focus was on patients with a work-related trauma (A) within the past month or (B) >6 months.

PRIMARY OUTCOME

frequency of work trauma-related chronic pain (>6 months) at the initial interview (point prevalence), secondary outcomes: frequency of chronicity at 6 months (A) and persistence of chronic pain (B). Tertiary outcomes: ability to work, occupational injury classification, burden based on pain intensity, localization, and medication, functional deficits due to the existence of chronic pain, and comorbidity.

RESULTS

Out of 415 patients included in the survey, 85% (160/188) reported accident-related chronic pain (predominantly moderate to highly severe in intensity, localized at joints and bones). 90% (131/145) also reported this pain six months later. 67% (64/96) reported chronic pain for the first time. Patients with chronic pain at follow-up (281/369) were less likely to return to work (p=0.003), required analgesics in 60%, were more often comorbid (p<0.002) and had greater functional deficits (p<0.002).

CONCLUSION

Despite the preliminary nature of the data, chronic pain seems to be common after occupational trauma and negatively affects the recovery of work ability in the long term. Based on the present observational data, a further differentiated re-evaluation of prospective data considering therapeutic measures is strongly recommended.

Notified occupational mental disorders: associations with health and income

BACKGROUND

Studies indicate that workers' compensation claim processes may affect patients' health negatively. However, few studies focus on patients with mental health claims, and the claim process varies between countries.

AIMS

The aims of this study were to examine whether being notified to the Danish Labour Market Insurance with an occupational mental health condition was associated with changes in visits to the general practitioner (GP), use of medicine and annual income.

METHODS

Study participants were 965 patients with a mental disorder examined at a department of occupational medicine. Of these, 669 patients were notified with an occupational mental disorder, 296 were not. Health-related outcomes, including GP visits and prescriptions of psychotropic drugs, were estimated at baseline during the year of medical examination, while annual income was estimated a year before the examination. The follow-up was the year after the year of examination for all outcomes. Outcomes were collected from the Danish National Bureau of Statistics. Analyses were conducted using Poisson regression and conditional logistic regression.

RESULTS

All measured outcomes decreased from baseline to follow-up in both groups. These changes were not significantly different depending on notification status at baseline.

CONCLUSIONS

This study suggests that being notified with an occupational mental disorder does not significantly affect health-related outcomes. A significant decrease in annual income over time was seen in both groups, the notified and the unnotified group, highlighting the importance of providing support to all employees with a mental disorder.

Understanding compensable and non-compensable patient profiles, pathways and physical outcomes for transport and work-related injuries in Queensland, Australia through data linkage

INTRODUCTION

In many jurisdictions, people experiencing an injury often pursue compensation to support their treatment and recovery expenses. Healthcare costs form a significant portion of payments made by compensation schemes. Compensation scheme regulators need accurate and comprehensive data on injury severity, treatment pathways and outcomes to enable scheme modelling, monitoring and forecasting. Regulators routinely rely on data provided by insurers which have limited healthcare information. Health data provide richer information and linking health data with compensation data enables the comparison of profiles, patterns, trends and outcomes of injured patients who claim and injured parties who are eligible but do not claim.

METHODS AND ANALYSIS

This is a retrospective population-level epidemiological data linkage study of people who have sought ambulatory, emergency or hospital treatment and/or made a compensation claim in Queensland after suffering a transport or work-related injury, over the period 1 January 2011 to 31 December 2021. It will use person-linked data from nine statewide data sources: (1) Queensland Ambulance Service, (2) Emergency Department, (3) Queensland Hospital Admitted Patients, (4) Retrieval Services, (5) Hospital Costs, (6) Workers' Compensation, (7) Compulsory Third Party Compensation, (8) National Injury Insurance Scheme and (9) Queensland Deaths Registry. Descriptive, parametric and non-parametric statistical methods and geospatial analysis techniques will be used to answer the core research questions regarding the patient's health service use profile, costs, treatment pathways and outcomes within 2 years postincident as well as to examine the concordance and accuracy of information across health and compensation databases.

ETHICS AND DISSEMINATION

Ethics approval was obtained from the Royal Brisbane and Women's Hospital Human Research Ethics Committee, and governance approval was obtained via the Public Health Act 2005, Queensland. The findings of this study will be used to inform key stakeholders across the clinical, research and compensation regulation area, and results will be disseminated through peer-reviewed journals, conference presentations and reports/seminars with key stakeholders.

Employees with mental disorders seeking support from the workers compensation system - experiences from Denmark

BACKGROUND

In Europe it is commonly accepted that psychosocial hazards may influence the mental health of employees. However, mental disorders such as depression are generally not acknowledged as an occupational disease covered by the workers compensation system. Studies indicate that workers compensation claim processes may affect employee's health negatively due to a demanding case process. If filing a workers' compensation claim can harm the employees' health, it is highly relevant to pay attention to employees with mental health claims, as they are most likely vulnerable and face a very low chance of compensation.

OBJECTIVE

This study investigates how employees with work-related mental disorders experience the process of seeking workers compensation from the Danish Workers' Compensation System.

METHOD

Interview (N = 13) and questionnaire (N = 436) data from claimants were analysed.

RESULTS

Analysis showed that even though many employees wished for the claim to influence the conditions at the workplace, there seemed to be a lack of preventive health and safety initiatives in the workplaces. Central stakeholders such as health and safety representatives were often not involved. Management involvement was often experienced negatively, and the Danish Working Environment Authority rarely conducted workplace inspections. Employees experienced inadequate information about the workers' compensation process and experienced a lack of coordination between stakeholders.

CONCLUSION

A more supportive and coordinated approach in the Workers' Compensation System is recommendable. The processes in the system could be evaluated using the Social Insurance Literacy concept, to ensure sufficient support of the claimants and reduce potential harmful aspects of the process.

Effects of seeking compensation on the psychological health and recovery of injured patients: the role of stress vulnerability and injury-related disability

BACKGROUND

Seeking compensation has been shown to have an adverse effect on the psychological health and recovery of injured patients, however, this effect requires clarification.

METHODS

A total of 2019 adults sustaining a traffic injury were recruited. Of these, 709 (35.1%) lodged a compensation claim. Interviews occurred at 1-, 6- and 12-month post-injury. Outcomes were psychological distress (posttraumatic stress (PTS) and depressive symptoms) and health-related functioning (HrF) (quality of life measured by EQ-5D-3L and disability by WHODAS) over 12-months post-injury. Covariates included individual stress vulnerability (preinjury, injury-related factors).

RESULTS

Compared with non-compensation participants, compensation groups had higher stress vulnerability (more severe injuries and negative reactions) and poorer baseline outcomes (psychological health and HrF). After adjustment, we found an effect of compensation on HrF [β-0.09 (-0.11 to -0.07), p < 0.001] and PTS [β = 0.36 (0.16 to 0.56), p = 0.0003], but not on depression [β = -0.07 (-0.42 to 0.28), p = 0.7]. Both groups improved over time. Vulnerable individuals (β = 1.23, p < 0.001) and those with poorer baseline outcomes (PTS: β = 0.06, p = 0.002; HrF: β = -1.07, p < 0.001) were more likely to lodge a claim. In turn, higher stress vulnerability, poor baseline outcomes and claiming compensation were associated with long-term psychological distress and HrF. Nevertheless, concurrent HrF in the model fully accounted for the compensation effect on psychological distress (β = -0.14, p = 0.27), but not vice versa.

CONCLUSIONS

This study provides convincing evidence that seeking compensation is not necessarily harmful to psychological health. The person's stress vulnerability and injury-related disability emerge as major risk factors of long-term psychological distress, requiring a whole-systems approach to address the problem.

Psychosocial impacts of post-disaster compensation processes: Community-wide avoidance behaviors

RATIONALE

There is a small but growing body of literature on litigation- and compensation-related stress after disasters. Results of these studies are consistent and unsurprising: compensation processes are a source of stress to plaintiffs and their families. "Litigation Response Syndrome"-anxiety, stress, and depression-is common among those exposed to the pressures of litigation (Lees-Haley 1988). However, little is known about how compensation processes-claims, litigation, and settlements-affect communities at large.

OBJECTIVE

Building on prior research, we examine adverse impacts of compensation processes in Roane County, Tennessee five years following the Tennessee Valley Authority coal ash spill. We investigate whether compensation-related stress occurs at a community level, as well as avoidance behaviors as measured by the Impact of Event Scale.

METHOD

Based on data from a 2014 household mail survey of a random sample of 716 residents of Roane County, we examine the relationship between compensation processes and event-related avoidance behaviors.

RESULTS

We found that compensation-related stress is not limited to those directly involved with compensation processes. Respondents view these processes as adversely impacting the community at large. The strongest contributors to event-related avoidance behaviors are beliefs about adverse compensation impacts and the effectiveness of cleanup and restoration activities, socioeconomic status, and economic resource loss. Therefore, it appears that Litigation Response Syndrome can extend to some members of the community who were not directly involved in litigation and compensation processes.

Database combinations to retrieve systematic reviews in overviews of reviews: a methodological study

Background

When conducting an Overviews of Reviews on health-related topics, it is unclear which combination of bibliographic databases authors should use for searching for SRs. Our goal was to determine which databases included the most systematic reviews and identify an optimal database combination for searching systematic reviews.

Methods

A set of 86 Overviews of Reviews with 1219 included systematic reviews was extracted from a previous study. Inclusion of the systematic reviews was assessed in MEDLINE, CINAHL, Embase, Epistemonikos, PsycINFO, and TRIP. The mean inclusion rate (% of included systematic reviews) and corresponding 95% confidence interval were calculated for each database individually, as well as for combinations of MEDLINE with each other database and reference checking.

Results

Inclusion of systematic reviews was higher in MEDLINE than in any other single database (mean inclusion rate 89.7%; 95% confidence interval [89.0–90.3%]). Combined with reference checking, this value increased to 93.7% [93.2–94.2%]. The best combination of two databases plus reference checking consisted of MEDLINE and Epistemonikos (99.2% [99.0–99.3%]). Stratification by Health Technology Assessment reports (97.7% [96.5–98.9%]) vs. Cochrane Overviews (100.0%) vs. non-Cochrane Overviews (99.3% [99.1–99.4%]) showed that inclusion was only slightly lower for Health Technology Assessment reports. However, MEDLINE, Epistemonikos, and reference checking remained the best combination. Among the 10/1219 systematic reviews not identified by this combination, five were published as websites rather than journals, two were included in CINAHL and Embase, and one was included in the database ERIC.

Conclusions

MEDLINE and Epistemonikos, complemented by reference checking of included studies, is the best database combination to identify systematic reviews on health-related topics.

Beyond symptom resolution: insurance case manager's perspective on predicting recovery after motor vehicle crash

PURPOSE

Insurance company case managers can play a critical role in the rehabilitation process of people with musculoskeletal disorders sustained following minor motor vehicle crash injury due to their interaction with multiple stakeholders and their role in approving various services. This study aimed to identify factors that case managers perceive as predictive of recovery in people with musculoskeletal disorders after minor motor vehicle crash injury.

MATERIALS AND METHODS

To explore the perspectives of cases managers in Australia and the United States, semi-structured interviews explored factors that case managers thought provided an early indication of likely recovery outcomes in people with musculoskeletal disorders after minor motor vehicle crash injury. A framework analysis was applied and factors were displayed within the ICF-framework.

RESULTS

Case managers (n = 40) demonstrated a broad, detailed understanding of biopsychosocial and contextual issues influencing recovery. They emphasized the importance of the injured worker's expressed affect and motivation, style of communication, the role of lawyers, the worker's family and friends, as well as cultural and geographic influences. The overarching themes perceived as having a major influence on recovery outcomes were general health, pain processing and response, work situation, and compensation entitlement.

CONCLUSIONS

Case managers' broad and detailed perceptions about recovery may provide additional, valuable perspectives for professionals involved in the rehabilitation process of people with musculoskeletal disorders after minor motor vehicle crash injury. Further research needs to be conducted to explore the effects of case manager involvement in the process of recovery.Implications for rehabilitationInsurance Case Managers identified multiple factors including affect and motivation, style of communication, the role of lawyers, family and friends, cultural and geographic variation provide opportunities for more effective treatment of people with musculoskeletal disorders related to minor motor vehicle collisions. These managers' perceptions about recovery may be informative to and provide opportunities for health professionals involved in the rehabilitation of people with musculoskeletal disorders related to minor motor vehicle collisions.While the Insurance Case Managers involved in this research did not use formalized assessment techniques, tools and assessment protocols could be developed jointly between for the needs of Insurance Case Managers and other stakeholders to tackle recovery of people with musculoskeletal disorders related to minor motor vehicle collision.

Chronic Pain Following Motor Vehicle Collision: A Systematic Review of Outcomes Associated With Seeking or Receiving Compensation

OBJECTIVE

Motor vehicle collisions (MVC) are a major cause of injury, which frequently lead to chronic pain and prolonged disability. Several studies have found that seeking or receiving financial compensation following MVC leads to poorer recovery and worse pain. We evaluated the evidence for the relationship between compensation and chronic pain following MVC within a biopsychosocial framework.

METHOD

A comprehensive search of 5 computerized databases was conducted. Methodological quality was evaluated independently by 2 researchers according to formal criteria, and discrepancies were resolved with a third reviewer.

RESULTS

We identified 5619 studies, from which 230 full-text articles were retrieved and 27 studies were retained for appraisal. A third of studies (37%) were of low quality, and 44% did not measure or control for factors such as injury severity or preinjury pain and disability. Most studies (70%) reported adverse outcomes, including all of the highest quality studies. Engagement with compensation systems was related to more prevalent self-reported chronic pain, mental health disorders, and reduced return to work. Recovery was poorer when fault was attributed to another, or when a lawyer was involved. Five studies compared Tort "common law" and No-Fault schemes directly and concluded that Tort claimants had poorer recovery.

CONCLUSIONS

Although causal relationships cannot be assumed, the findings imply that aspects of loss, injustice, and secondary mental health outcomes lead to chronic pain following MVC. Further robust prospective research is required to understand the complex relationship between compensation systems and pain following road trauma, particularly the role of secondary mental health outcomes.

The Nature of Whiplash in a Compensable Environment: Injury, Disability, Rehabilitation, and Compensation Systems

Synopsis Whiplash is a compensable injury in many jurisdictions, but there is considerable heterogeneity in the compensation arrangements that apply across jurisdictions, even within some countries. These compensation schemes have, however, been subject to a common set of interrelated concerns, chiefly concerning the incentives, behaviors, and outcomes that may arise when financial compensation for injuries is available to injured parties. This article provides a nontechnical overview of some of those concerns through the lens of economics: principally, insurance economics and health economics, including related subsets such as information economics and agency theory, as well as economics and the law. It notes that because it is generally infeasible to randomize the treatment (ie, compensation) via trials, analyses of observational data are necessary to discover more about the relationship between compensation and health outcomes. This poses the analytical challenge of discovering causal connections between phenomena from nonrandomized data sets. The present article calls for further research that would enable convincing causal interpretations of such relationships via the careful analysis of rich observational data sets using modern econometric methods. J Orthop Sports Phys Ther 2017;47(7):503-508. Epub 16 Jun 2017. doi:10.2519/jospt.2017.7533.

How Do We Meet the Challenge of Whiplash?

A previous special issue of JOSPT (October 2016) discussed whiplash in terms of the clinical problems and current research surrounding prevention, biomechanics of injury, emergent care, imaging advancements, recovery pathways and prognosis, pathogenesis of posttrauma pain, acute and chronic management, and new predictive clinical tools. While great strides have been made in the field of whiplash and are continuing in earnest, a key group of clinicians and academics have recognized that inconsistent outcomes in published literature hamper our ability to meaningfully synthesize research findings, leading to results of systematic reviews that provide very few concrete clinical recommendations. We are optimistic that improved outcomes for people with whiplash-associated disorder (WAD) are attainable in the near future, as interdisciplinary research efforts continue to align internationally, new mechanisms are identified and explored, and advanced statistical techniques allow complex questions to be answered in clinically meaningful ways. J Orthop Sports Phys Ther 2017;47(7):444-446. doi:10.2519/jospt.2017.0106.

The Effect of Workers' Compensation on Outcome Measurement Methods after Upper Extremity Surgery: A Systematic Review and Meta-Analysis

BACKGROUND

Patients who receive workers' compensation often display worse surgical results, such as prolonged pain or reduced functional ability. The outcomes of surgery can be assessed using a variety of surveys, assessments, and measurements. It is unknown whether the confounding effect differs based on how results are measured. The aim of this study was to determine whether these variations exist.

METHODS

A search of full-length articles published between January 1, 1995, and December 31, 2015, was conducted using 3 online databases. The authors performed a systematic review and meta-analysis using unique inclusion criteria for each.

RESULTS

A total of 101 articles were included in the systematic review; 62 of them were retained for the meta-analysis. In the systematic review, 70 percent of studies found that patients receiving workers' compensation had significantly worse postoperative results than uncompensated patients, whereas only 42 percent of studies that measured preoperative versus postoperative improvement were influenced by workers' compensation. The meta-analysis found that uncompensated patients were more likely to experience improvement after surgery than patients receiving workers' compensation (summary OR, 3.17; 95 percent CI, 2.47 to 4.08). A subgroup analysis demonstrated that functional measures, such as grip strength or nonunion, were least affected by workers' compensation, compared with other outcome measures such as patient-reported outcomes questionnaires or time off work.

CONCLUSION

Potential bias introduced by workers' compensation can be mitigated by evaluating surgical treatment of work-related upper extremity disorders using preoperative versus postoperative improvement or functional measures.

Negative impact of litigation procedures on patient outcomes four years after severe traumatic brain injury: results from the PariS-traumatic brain injury study

PURPOSE

To analyze the effect of litigation procedures on long-term outcomes in severe traumatic brain injury.

MATERIALS AND METHODS

Prospective observational follow-up of an inception cohort including 504 adults with severe traumatic brain injury recruited in 2005-2007 in the Parisian area, France, with initial, one- and four-year outcomes measures.

RESULTS

Four years after the traumatic brain injury, 147 patients, out of 257 who survived the acute phase, were assessed. Among these patients, 53 patients declared being litigants and 78 nonlitigants (litigation status was unknown in 16 cases). Sociodemographic characteristics, type of injury and initial severity did not differ significantly between litigants and nonlitigants, except for Injury Severity Score (worse in litigants) and the proportion of road traffic accidents (higher in litigants). One- and four-year outcomes were significantly worse in litigants for autonomy, participation, psychiatric and cognitive function but not quality of life (measured with the Glasgow Outcome Scale-Extended, the working activity status, the Brain Injury Community Rehabilitation Outcome, the Hospital Anxiety and Depression scale, the Neurobehavioral Rating Scale-revised and the Quality of Life after Brain Injury, respectively). Multivariate analyses highlighted litigation procedure as an independent significant predictor of lower autonomy, participation and psychiatric function and tended to predict lower cognitive function, but not lower quality of life, after adjustment for pretrauma characteristics, Injury Severity Score, road traffic accidents and work-related accident status.

CONCLUSIONS

Patients with severe traumatic brain injury have a worse prognosis when involved in a litigation procedure and require special attention in clinical practice. Implications for rehabilitation The influence of litigation procedure on health and social outcomes in severe traumatic brain injury is a major issue that entail numerous levels of complexities. A wide range of interactions and factors related to the prolonged process of litigation against a third party may influence recovery. Results from the PariS-Traumatic Brain Injury study suggest that patients with a severe Traumatic Brain Injury who are involved in a litigation procedure within French jurisdiction compensation scheme have a worse prognosis than patients who do not. Health professionals should be aware of the potential adverse effects of litigation procedures on recovery, and provide appropriate interventions and information to patients and families in such cases.

Predictors of seeking financial compensation following motor vehicle trauma: inception cohort with moderate to severe musculoskeletal injuries

BACKGROUND

Compensation related factors have been repeatedly associated with poor recovery following orthopaedic trauma. There is limited research into the factors associated with seeking financial compensation. Further understanding of these factors could facilitate injury recovery by purposeful compensation scheme design. The aim of this study was to investigate the predictors of seeking financial compensation, namely making a claim and seeking legal representation, following motor vehicle related orthopaedic trauma. The study was conducted in New South Wales (NSW), Australia, in motor vehicle crash and workers' compensation schemes.

METHODS

Participants were patients admitted with upper or lower extremity factures following a motor vehicle crash to two trauma hospitals. Data were collected at baseline within two weeks of injury. Participants were followed up at six months. Analysis involved: descriptive statistics for baseline characteristics; comparison of compensable and non-compensable participants with Analysis of Variance (ANOVA) and chi-squared tests; and logistic regression for predictor models.

RESULTS

The cohort consisted of 452 participants with a mean age 40 years; 75% male; 74% working pre-injury; 30% in excellent pre-injury health; 56% sustained serious injuries with an Injury Severity Score (ISS) 9-15; 61% had a low-middle range household income; and 35% self-reported at fault in the crash. There was no significant difference in pre-injury/baseline health between compensable and non-compensable participants. Follow up data was available for 301 (67%) participants. The significant predictor of claiming compensation in the adjusted analysis was higher body mass index (BMI) (overweight Odds Ratio [OR] 3.05, 95% Confidence Interval [CI] 1.63-5.68; obese OR 1.63, 95% CI 0.83-3.20). Participants less likely to claim were: involved in a motorcycle crash (OR 0.47, 95% CI 0.28-0.82); socioeconomically less disadvantaged (OR 0.37, 95% CI 0.17-0.82) or least disadvantaged (OR 0.39, 95% CI 0.17-0.90); at risk for short term harm (injury) due to alcohol consumption (OR 0.56, 95% CI 0.32-0.97); and with fair-poor pre-injury health (OR 0.30, 95% CI 0.09-0.94). The predictors for seeking legal representation were speaking a language other than English at home (OR 2.80, 95% CI 1.2-6.52) and lower household income (OR 3.63, 95% CI 1.22-10.72). Participants less likely to seek legal representation were least socioeconomically disadvantaged (OR 0.15, 95% CI 0.04-0.50).

CONCLUSIONS

Seeking financial compensation was associated with a higher pre-injury BMI rather than injury-related factors. Seeking legal representation was solely related to socio-economic factors.

Whiplash Continues Its Challenge

There have been many advances in the management of neck pain disorders, but a personal frustration as a clinician and researcher in the field is that the incidence of full recovery following a whiplash injury as a result of a motor vehicle crash has not increased and, subsequently, the rate of transition to chronic neck pain has not lessened. The commentaries in this special issue reflect the multifaceted nature of whiplash-associated disorders and the wide-ranging research in the field. While management of whiplash, especially the challenge of lessening the rate of transition to chronicity, has yet to be achieved, the picture is becoming clearer. This should give great confidence and some hope to individuals with whiplash-associated disorders who have long-term pain and functional disability that after the next decade of research and clinical development, the outcomes following whiplash are likely to be vastly improved. J Orthop Sports Phys Ther 2016;46(10):815-817. doi:10.2519/jospt.2016.0112.

Psychological impact of injuries sustained in motor vehicle crashes: systematic review and meta-analysis

OBJECTIVE

The aim of this meta-analysis was to determine the psychological impact associated with motor vehicle crash (MVC)-related physical injuries.

DESIGN

Systematic review and meta-analysis.

DATA SOURCES

Multiple search engines included MEDLINE (via OVID), PsycINFO and Embase, and studies were sourced from scientific journals, conference papers and doctoral theses.

STUDY SELECTION

A high-yield search strategy was employed. Terms like 'psychological distress', 'depression', 'PTSD' and 'motor vehicle accident' were employed. These key words were run primarily and secondary searches were then conducted in association with the major injury types. Studies needed to compare psychological distress in people injured in an MVC with uninjured controls who had not recently experienced an MVC.

DATA EXTRACTION

Searches resulted in the identification of 2537 articles, and after eliminating duplicates and studies not meeting inclusion criteria, 24 studies were selected involving 4502 injured participants. These studies were entered into separate meta-analyses for mild to moderate traumatic brain injury (mTBI), whiplash-associated disorder (WAD) and spinal cord injury (SCI).

RESULTS

Elevated psychological distress was associated with MVC-related injuries with a large summary effect size in WAD (0.90), medium to large effect size in SCI (0.69) and small to medium effect size in mTBI (0.23). No studies meeting inclusion criteria were found for burns, fractures and low back injury. Increased psychological distress remains elevated in SCI, mTBI and WAD for at least 3 years post-MVC.

CONCLUSIONS

Rehabilitation strategies are needed to minimise distress subsequent to MVC-related physical injuries and the scientific robustness of studies requires improvement.

The association between seeking financial compensation and injury recovery following motor vehicle related orthopaedic trauma

BACKGROUND

Motor vehicle related moderate-severe orthopaedic trauma has a major impact on the burden of injury. In Australia, all states and territories provide access to financial compensation following injury in a motor vehicle crash. The aim of this study was to investigate the influence of seeking financial compensation (i.e., making a claim) on injury recovery following motor vehicle related moderate-severe orthopaedic trauma.

METHODS

Patients admitted with upper/lower extremity fractures after a motor vehicle crash were recruited from two trauma hospitals. Baseline data were collected in person by written questionnaire within two weeks of injury. Follow up data were collected by a mailed written questionnaire at six, 12 and 24 months. Additional (demographic/injury-related) information was collected from hospital databases, all other measures were self-reported. Outcomes were: Short Form-36 Version 2.0 (SF36v2), Physical/Mental Component Scores (PCS/MCS); Post Traumatic Stress Disorder (PTSD) Checklist Civilian Version (PCL-C); and Global Rating of Change (GRC) scale. Analysis involved descriptive statistics and linear mixed models to examine the effect of compensation status on injury recovery over time.

RESULTS

There were 452 study participants. Baseline characteristics showed: mean age 40 years (17.1 Standard Deviation [SD]); 75 % male; 74 % worked pre-injury; 67 % in excellent-very good pre-injury health; 56 % sustained serious injuries, Injury Severity Score (ISS) 9-15; 61 % had a low-middle range household income. Overall, after controlling for possible confounders, the compensable group had poorer recovery compared to the non-compensable group for PCS (-2.97 Mean Difference (MD), 95 % CI -4.73, -1.22); MCS (-3.44 MD, 95 % CI -5.62, -1.26); PCL-C (3.42MD, 95 % CI 0.87, 5.99); and GRC (-0.66MD, 95 % CI -1.15, -0.17). Injury recovery over time for all participants showed: PCS improved from 6-12 and 12-24 months; MCS and GRC improved from 6-12 months; and PCL-C did not significantly improve from 6-12 and 12-24 months. Injury recovery over time continued for compensable and non-compensable groups but compensable participants had poorer scores at each time period, especially MCS and PCL-C.

CONCLUSIONS

Making a claim was associated with poor injury recovery following motor vehicle related orthopaedic trauma, mainly for mental health. Irrespective of claim status, the majority had poor injury recovery, especially for mental health.

Healing or harming? Healthcare provider interactions with injured workers and insurers in workers' compensation systems

INTRODUCTION

Healthcare providers (HCPs) are influential in the injured worker's recovery process and fulfil many roles in the delivery of health services. Interactions between HCPs and insurers can also affect injured workers' engagement in rehabilitation and subsequently their recovery and return to work. Consideration of the injured workers' perceptions and experiences as consumers of medical and compensation services can provide vital information about the quality, efficacy and impact of such systems. The aim of this systematic review was to identify and synthesize published qualitative research that focused on the interactions between injured workers, HCPs and insurers in workers' compensation systems in order to identify processes or interactions which impact injured worker recovery.

METHOD

A search of six electronic databases for literature published between 1985 and 2012 revealed 1,006 articles. Screening for relevance identified 27 studies which were assessed for quality against set criteria. A final 13 articles of medium and high quality were retained for data extraction.

RESULTS

Findings were synthesized using a meta-ethnographic approach. Injured workers reported that HCPs could play both healing and harming roles in their recovery. Supportive patient-centred interaction with HCPs is important for injured workers. Difficult interactions between HCPs and insurers were highlighted in themes of adversarial relations and organisational pressures. Insurer and compensation system processes exerted an influence on the therapeutic relationship. Recommendations to improve relationships included streamlining administrative demands and increasing education and communication between the parties.

CONCLUSION

Injured workers with long term complex injuries experience difficulties with healthcare in the workers' compensation context. Changes in insurer administrative demands and compensation processes could increase HCP participation and job satisfaction. This in turn may improve injured worker recovery. Further research into experiences of distinct healthcare professions with workers' compensation systems is warranted.

The effect of financial compensation on health outcomes following musculoskeletal injury: systematic review

The effect of financial compensation on health outcomes following musculoskeletal injury requires further exploration because results to date are varied and controversial. This systematic review identifies compensation related factors associated with poorer health outcomes following musculoskeletal injury. Searches were conducted using electronic medical journal databases (Medline, CINAHL, Embase, Informit, Web of Science) for prospective studies published up to October 2012. Selection criteria included: prognostic factors associated with validated health outcomes; six or more months follow up; and multivariate statistical analysis. Studies solely measuring return to work outcomes were excluded. Twenty nine articles were synthesised and then assessed using GRADE (Grading of Recommendations Assessment, Development and Evaluation) methodology to determine evidence levels. The results were mixed. There was strong evidence of an association between compensation status and poorer psychological function; and legal representation and poorer physical function. There was moderate evidence of an association between compensation status and poorer physical function; and legal representation and poorer psychological function. There was limited evidence of an association between compensation status and increased pain. In seven studies the association depended on the outcome measured. No studies reported an association between compensation related factors and improved health outcomes. Further research is needed to find plausible reasons why compensation related factors are associated with poorer health following musculoskeletal injury.

One Year After Mild Injury: Comparison of Health Status and Quality of Life Between Patients with Whiplash Versus Other Injuries

Objective.

To compare health status, effect on family, occupational consequences, and quality of life (QOL) 1 year after an accident between patients with whiplash versus other mild injuries, and to explore the relationship between initial injury (whiplash vs other) and QOL.

Methods.

This was a prospective cohort study. The study used data from the ESPARR cohort (a representative cohort of road accident victims) and included 173 individuals with “pure” whiplash and 207 with other mild injuries. QOL at 1-year followup was assessed on the World Health Organization Quality of Life questionnaire. Correlations between explanatory variables and QOL were explored by Poisson regression to provide adjusted relative risks, with ANOVA for the various QOL scores explored.

Results.

One year post-accident, more patients who had whiplash than other casualties complained of nonrecovery of health status (56% vs 43%) and of the occupational effect of pain (31% vs 23%). QOL and posttraumatic stress disorder (PTSD) were similar in the 2 groups. Impaired QOL did not correlate with whiplash when models were adjusted on sociodemographic variables and history of psychological distress. Whatever the initial lesion, PTSD was a determining factor for poorer QOL.

Conclusion.

Sociodemographic factors, preaccident psychological history prior to the accident, and PTSD were the main factors influencing QOL, rather than whether the injury was whiplash. PTSD may also be related to pain.

The Neck Pain Driving Index (NPDI) for chronic whiplash-associated disorders: development, reliability, and validity assessment

BACKGROUND CONTEXT

Driving is a functional complaint of many individuals with chronic whiplash-associated disorders (WAD). Current driving scales do not include the most troublesome driving tasks for this group, which suggests that a new tool is required to assess perceived driving difficulty in this population.

PURPOSE

To develop a Neck Pain Driving Index (NPDI) to assess the degree of perceived driving difficulty for individuals with chronic WAD and evaluate the reliability and validity of the NPDI.

STUDY DESIGN

Descriptive/survey.

PATIENT SAMPLE

An external panel of 15 researchers/clinicians and 87 participants with chronic WAD.

OUTCOME MEASURES

The NPDI and a 0 to 10 numeric rating scale (NRS) of perceived driving difficulty (0, no difficulty and 10, maximum difficulty).

METHODS

Phase 1 included the construction of a preliminary NPDI and content validity assessment of question items by a 15-member external panel. Comprehension was evaluated by seven participants with chronic WAD. In Phase 2, the final version of the NPDI was developed via descriptive analysis and assessment of internal consistency using responses of 87 participants with chronic WAD. Subsequently, the convergent validity was assessed using NRS scores. Test-retest reliability at 1 month was investigated in 25 of the 87 participants. Psychometric properties of the driving tasks in the final NPDI were categorized by the external panel, based on the hierarchal Michon model of driving task performance levels. An additional symptom section was developed to better understand the reasons for driving difficulties.

RESULTS

The final NPDI included 12 driving tasks, which scored at least 80% on the content validity index (CVI), ensuring content validity. The NPDI demonstrated good internal consistency (α=0.80), convergent validity (ρ=0.51; p<.01), and test-retest reliability (intraclass correlation coefficient, 0.73; p<.01). As a result of the assessment of psychometric properties, driving tasks were categorized into the strategic (n=3), tactical (n=7), and operational (n=2) levels in the Michon model. The content validity of 11 symptoms (CVI ≥80%) was established by the external panel.

CONCLUSIONS

The NPDI was developed to assess the degree of perceived driving difficulty in the chronic whiplash population. Reliability and validity of the NPDI were ensured. The NPDI can be the entry point for discussions on driving difficulties between clinicians and patients with chronic WAD.

Preserving workers' dignity in workers' compensation systems: an international perspective

BACKGROUND

Workers' compensation systems are among the most generous disability insurance systems in North America, although they are also known to be potentially adversarial and may have iatrogenic effects on claimants. This article examines issues to be considered to ensure fair compensation provided in a way that respects the dignity of workers.

METHODS

An overview of the literature on characteristics and effects of workers' compensation systems is followed by an analysis based on classic legal methods, including those of comparative law, complemented with interview data to examine three models of disability compensation.

RESULTS

The first part of the article identifies cross cutting issues to be considered in the examination of the equity of compensation systems and the protection of the dignity of claimants. These include three underpinnings of workers' compensation: the links between a "no-fault" system and the adversarial process, the appropriate use of medical and scientific evidence in the determination of compensability and the application of appropriate measures for promoting return to work. The second part looks at accident compensation in New Zealand, where compensation is available regardless of the cause of the accident, and disability insurance in the Netherlands, where compensation is available regardless of the cause of the disability. It then describes a composite of characteristics favorable to equity drawn from the thirteen workers' compensation systems in Canada.

CONCLUSION

Systems that succeed in reducing opportunities for adversarial interactions and that provide substantive protection could better promote the dignity of claimants.

Whiplash and the compensation hypothesis

STUDY DESIGN

Review article.

OBJECTIVE

To explain why the evidence that compensation-related factors lead to worse health outcomes is not compelling, either in general, or in the specific case of whiplash.

SUMMARY OF BACKGROUND DATA

There is a common view that compensation-related factors lead to worse health outcomes ("the compensation hypothesis"), despite the presence of important, and unresolved sources of bias. The empirical evidence on this question has ramifications for the design of compensation schemes.

METHODS

Using studies on whiplash, this article outlines the methodological problems that impede attempts to confirm or refute the compensation hypothesis.

RESULTS

Compensation studies are prone to measurement bias, reverse causation bias, and selection bias. Errors in measurement are largely due to the latent nature of whiplash injuries and health itself, a lack of clarity over the unit of measurement (specific factors, or "compensation"), and a lack of appreciation for the heterogeneous qualities of compensation-related factors and schemes. There has been a failure to acknowledge and empirically address reverse causation bias, or the likelihood that poor health influences the decision to pursue compensation: it is unclear if compensation is a cause or a consequence of poor health, or both. Finally, unresolved selection bias (and hence, confounding) is evident in longitudinal studies and natural experiments. In both cases, between-group differences have not been addressed convincingly.

CONCLUSION

The nature of the relationship between compensation-related factors and health is unclear. Current approaches to testing the compensation hypothesis are prone to several important sources of bias, which compromise the validity of their results. Methods that explicitly test the hypothesis and establish whether or not a causal relationship exists between compensation factors and prolonged whiplash symptoms are needed in future studies.

Complexities in understanding the role of compensation-related factors on recovery from whiplash-associated disorders: discussion paper 2

STUDY DESIGN

Focused discussion.

OBJECTIVE

To present some of the complexities in conducting research on the role of compensation and compensation-related factors in recovery from whiplash-associated disorders (WAD) and to suggest directions for future research.

SUMMARY OF BACKGROUND DATA

There is divergence of opinion, primary research findings, and systematic reviews on the role of compensation and/or compensation-related factors in WAD recovery.

METHODS

The topic of research of compensation/compensation-related factors was discussed at an international summit meeting of 21 researchers from diverse fields of scientific enquiry. This article summarizes the main points raised in that discussion.

RESULTS

Traffic injury compensation is a complex sociopolitical construct, which varies widely across jurisdictions. This leads to conceptual and methodological challenges in conducting and interpreting research in this area. It is important that researchers and their audiences be clear about what aspect of the compensation system is being addressed, what compensation-related variables are being studied, and what social/economic environment the compensation system exists in. In addition, summit participants also recommended that nontraditional, sophisticated study designs and analysis strategies be employed to clarify the complex causal pathways and mechanisms of effects.

CONCLUSION

Care must be taken by both researchers and their audiences not to overgeneralize or confuse different aspects of WAD compensation. In considering the role of compensation/compensation-related factors on WAD and WAD recovery, it is important to retain a broad-based conceptualization of the range of biological, psychological, social, and economic factors that combine and interact to define and determine how people recover from WAD.

Empowerment of personal injury victims through the internet: design of a randomized controlled trial

BACKGROUND

Research has shown that current claims settlement process can have a negative impact on psychological and physical recovery of personal injury (PI) victims. One of the explanations for the negative impact on health is that the claims settlement process is a stressful experience and victims suffer from renewed victimization caused by the claims settlement process. PI victims can experience a lack of information, lack of involvement, lack of 'voice', and poor communication. We present the first study that aims to empower PI victims with respect to the negative impact of the claims settlement process by means of an internet intervention.

METHODS/DESIGN

The study is a two armed, randomized controlled trial (RCT), in which 170 PI victims are randomized to either the intervention or control group. The intervention group will get access to a website providing 1) an information module, so participants learn what is happening and what to expect during the claims settlement process, and 2) an e-coach module, so participants learn to cope with problems they experience during the claims settlement process. The control group will get access to a website with hyperlinks to commonly available information only. Participants will be recruited via a PI claims settlement office. Participants are included if they have been involved in a traffic accident which happened less than two years ago, and are at least 18 years old.The main study parameter is the increase of empowerment within the intervention group compared to the control group. Empowerment will be measured by the mastery scale and a self-efficacy scale. The secondary outcomes are perceived justice, burden, well being, work ability, knowledge, amount of damages, and lawyer-client communication. Data are collected at baseline (T0 measurement before randomization), at three months, six months, and twelve months after baseline. Analyses will be conducted according to the intention-to-treat principle.

DISCUSSION

This study evaluates the effectiveness of an internet intervention aimed at empowerment of PI victims. The results will give more insight into the impact of compensation proceedings on health over time, and they can have important consequences for legal claims settlement. Strengths and limitations of this study are discussed.

TRIAL REGISTRATION

Netherlands Trial Register NTR2360.